How does your facility promote interprofessional collaboration during transitions?

Transitions in my facility include rehab to home, rehab to long term, or to hospice and death transition. If a resident is short term rehab, a transitions book is started at admission. When the resident has completed therapy then the book is filled out. Each department has a part from nursing, dietary, activities, social services, and therapy. The transitions nurse will obtain any needed scripts, home care will be set up if needed, future appointments are made and documented in the transitions book. Family training is provided if needed and nursing educates resident on anything they will need to do when they leave. We also have a nursing home transitions program that will help those that want to live independently find a place and set up services. Some residents transition to long term if family feels they cannot care for them anymore at home. In this case, the staff from the short term floor will collaborate with the nurse on the long term floor and information will be exchanged along with the medications and rooms will be changed. Another transition involving my facility is going on hospice. In this case, the doctors give the order and talk to the hospice service and then family gets involved with hospice and the nurses then know how to direct their care. Dietary also gets involved in this transition and will assess resident frequently to make sure his /her nutritional needs are being met. This transition also involves therapy if a new wheel chair is needed or if OT or speech is warranted. The nurses, doctors, and hospice workers collaborate all the time in this situation. All these situations involve teamwork, “Teamwork is a key element in any change process, it involves collaborative efforts in assessing, planning, implementing, and evaluating patient outcomes.” (Lesson wk #5) “The absence of interprofessional collaboration will lead to errors and omissions in patient care.” (Matziou, 2014) When a resident goes home, our transitions nurse will also follow up with them in a week then a month later.

What is the role of the nurse?

If a resident is going home, the nurse will provide education before discharge on medications or anything the resident needs from checking blood sugars, giving insulin, ostomy or wound care. The nurse also will do any assessments needed before discharge and work through their part of the transitions booklet. When a resident transfers floors the nurses give report and new assessments will be completed depending on the residents situation. In my facility the change of floors doesn’t bring a change in doctor which is nice for continuity of care. If a resident transitions to hospice, the nurse will talk to the hospice staff on noted things and give report on meal intake, medication administration, diagnosis, and they will continue to collaborate for the duration of the residents life.

Gaps identified in the process related to care?

There are not too many gaps, when social services knows a resident is discharging to home, they have their plan in place already and the transitions nurse will move forward to get the needed homecare or equipment at home. When a resident is short term, they are usually there for rehab and therapy will usually make the decision along with insurance to decide what discharge date will be so there is usually notice so things can be ready. If a resident is going long term, it is usually discussed in the morning meeting so the unit managers are aware and can pass it on to the staff on the floor the resident is transferring to. Then housekeeping gets involved to move the residents belongings. If a resident transfers to hospice services then it is noted also in morning meeting then social services gets involved with the referral for hospice to come in and evaluate. Usually, the system we have works well and no gaps are noted.

Chamberlain University College of Nursing. (2019). RN Capstone Course NR451-62005. Week Five Lesson. Retrieved from https://chamberlain.instructure.com/courses/45610/…

Matziou, V., Vlahioti, E., Perdikaris, P., Matziou, T., Megapanou, E., & Petsios, K. (2014). Physician and nursing perceptions concerning interprofessional communication and collaboration. Journal of Interprofessional Care, 28(6), 526–533. https://doi-org.chamberlainuniversity.idm.oclc.org…

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